Hypertension disorder during pregnancy (II)

(Management)
Dr Punita
NHBPEP (2002):
Gestational Hypertension:
• Systolic BP >/140 or diastolic BP >/90 mm Hg for first time
during pregnancy

• No proteinuria

• BP returns to normal before 12 weeks postpartum

• Final diagnosis made only postpartum

• May have other signs or symptoms of preeclampsia, for

example, epigastric discomfort or thrombocytopenia
Preeclampsia :
Minimum criteria:
• BP >/140/90 mm Hg after 20 weeks' gestation
• Proteinuria >/300 mg/24 hours or >/1+ dipstick
Increased certainty of preeclampsia:
• BP >/160/110 mm Hg
• Proteinuria 2.0 g/24 hours or >/ 2+ dipstick
• Serum creatinine >1.2 mg/dL unless known to be
previously elevated
• Platelets < 100,000/L
• Microangiopathic hemolysis—increased LDH
• Elevated serum transaminase levels—ALT or AST
• Persistent headache or other cerebral or visual disturbance
• Persistent epigastric pain
Eclampsia:
• Seizures that cannot be attributed to other causes in
a woman with preeclampsia.

Superimposed Preeclampsia On Chronic Hypertension:

• New-onset proteinuria>/ 300 mg/24 hours in
hypertensive women but no proteinuria before 20
weeks' gestation
• A sudden increase in proteinuria or blood pressure or
platelet count < 100,000/L in women with
hypertension and proteinuria before 20 weeks'
gestation
Chronic Hypertension:
• BP >/140/90 mm Hg before pregnancy or
diagnosed before 20 weeks' gestation not
attributable to gestational trophoblastic
disease
or
• Hypertension first diagnosed after 20 weeks'
gestation and persistent after 12 weeks
postpartum
• Hypertensive disorder of pregnancy is managed according
to :
 severity,
 gestational age,
 presence of preeclampsia

Objectives :
1. To stabilise hypertension and to prevent its progression to
severe pre-eclampsia.
2. To prevent the complications
3. To prevent eclampsia.
4. To deliver a healthy baby in optimal time.
5. Restoration of the health of the mother in puerperium.
 Home / day care
unit Early diagnosis of preeclampsia

Hospitalization

Systematic evaluation

Daily
examination and Edema Urine Blood Eye
I/O
watch for Weight Vitals examin examin exami
chart
imminient gain ation ation nation
features of
eclamsia
Fetal well
Period of
being, NST ,
gestation
BPP
Retina:
Grade 1 : arteriolar thickening, tortuosity and increased
reflectiveness (silver wiring)
Grade 2: grade 1 + constriction of veins at arteriolar
crossing (AV nipping)
Grade 3: grade 2 + evidence of ischemia ( flame shaped or
blot haemorrhages and cotton wool exudated )
Grade 4: grade 3 + papilloedema

• Central wool exudates are associated with retinal ischemia

or infarction.
• Sometimes hypertension is associated with retinal vein
thrombosis.
Rest:
left-lateral position – decrease effects of vena caval
compression.
(1) increases the renal blood flow → diuresis,
(2) increases the uterine blood flow → improves
the placental perfusion, and
(3) reduces the blood pressure.
Diet:
 Daily protein (about 100 gm).
 Total calorie approximate 1600 cal/day.
Diuretics
• Not prescribed – decrease placental perfusion
• Diuretics: frusemide
Use :
 Cardiac failure,
 Pulmonary edema,
 Along with selective antihypertensive drug therapy
(diazoxide group) where blood pressure reduction is
associated with fluid retention,
 Massive edema, not relieved by rest and producing
discomfort to the patient.
Anti-hypertensives:
Indications :
• Persistent rise of blood pressure specially
where the diastolic pressure is over 110 mm
Hg.

• In severe pre-eclampsia to bring down the

blood pressure during continued pregnancy
and during the period of induction of labor.
 ANTIHYPERTENSIVES:
Drug Mechanism Dose
Methyl dopa Central and peripheral anti 250-500 mg TID/QID
adrenergic action
Labetalol Adrenoreceptor antagonist 100 mg TID/ QID
( alpha and beta blocker)
Nifedipine Calcium channel blocker 10-20 mg BD

Hydralazine Vascular smooth muscle 10 – 25 mg BD

relaxant
 Hypertensive crisis
Drug Onset of Dose Max dose Maintenance
action dose
Labetalol 5 min 10-20 mg IV 300 mg IV 40 mg/ hr
every 1o min
Hydralazine 10 min 5 mg IV every 30 mg IV 10mg / hr
30 min
Nifedipine 10 min 10-20 mg oral 240 mg/ 24 hr 4-6 hr interval
can be
reapeated in 30
min
Nitroglycerine 0.5 to 5 5 microgm /
min min IV
Sodium nitroprusside 0.25 – 5
microgm /kg /
min IV
Favorable signs:
• fall of blood pressure and weight with subsidence of
edema.
• Urinary output increases with diminishing
proteinuria.

Consideration for Delivery:

• Termination of pregnancy is the only cure for
preeclampsia.

• Delayed delivery
Duration of treatment depends on :
(1) severity of pre-eclampsia,
(2) duration of pregnancy,
(3) response to treatment,
(4) condition of the cervix.

Depending on the response to the treatment, the patients are

grouped into the following:
A) Pre-eclamptic features subside and hypertension is mild.

B) Partial control of the pre-eclamptic features but the blood pressure

maintains a steady high level.

C) Persistently increasing BP to severe level, despite the use of

antihypertensive and/or addition of grave features such as headache,
epigastric pain, oliguria, blurring of vision or HELLP syndrome.
Group A:
• If the patient is preterm -discharge
• If the patient is near term, -plan for delivery

Group B:
• If the pregnancy is beyond 37 completed weeks, -
delivery .
• If less than 37 weeks, expectant treatment may be
extended judiciously at least up to 34 weeks.
 Careful maternal and fetal well-being are to be
monitored during the period.
Group C:
• Termination of pregnancy (delivery) is considered
irrespective of duration of gestation.

• Seizure prophylaxis (magnesium sulfate).

• Steroid therapy is considered if the duration of

pregnancy is < 34 weeks (enhances fetal lung
maturation and prevents neonatal RDS, IVH, and
maternal thrombocytopenia)
Some indications for delivery with early onset severe preeclampsia :
Maternal:
• Persistent severe headache or visual changes; eclampsia
• SOB, chest tightness with rales and or spo2 <94% in room air ,
pulmonary edema
• Uncontrolled severe HTN despite treatment ( 2 drugs – max dose)
• Oliguria <500ml/24 hrs or serum creatinine level 1.5mg/dl
• Persistent platelet count <100000/cmm
• Suspected abruption, progressive labour, and or ruptured membranes
Fetal:
• Severe growth restriction
• Persistent severe oligohydraminios
• BPP -4
• Reversed end diastolic umbilical artery flow
• Fetal death.
 Methods of delivery:
Induction of labor Cesarean section
Induction of labor:
1. Aggravation of the pre-eclamptic features in spite of
medical treatment and/or appearance of newer
symptoms such as epigastric pain.
2. Hypertension persists in spite of medical treatment
with pregnancy reaching 37 weeks or more.
3. Acute fulminating pre-eclampsia irrespective of the
period of gestation .
4. Tendency of pregnancy to overrun the EDD
• Cesarean section
Indications:
1. When an urgent termination is indicated and the
cervix is unfavorable (unripe and closed).

2. Severe pre-eclampsia with a tendency to prolong

the induction—delivery interval.

3. Associated complicating factors, such as elderly

primigravidae, contracted pelvis, malpresentation,
etc.
Management during labour:
• Blood pressure tends to rise during labor and
convulsions may occur (intrapartum eclampsia).
• Bed.
• Antihypertensive drugs
• Vitals and I/O charting .
• Prophylactic MgSO4 is started when systolic BP >160
diastolic >110, MAP >125 mm Hg.
• Careful monitoring of the fetal well-being is
mandatory
PUERPERIUM:
• Close monitor for at least 48 hours,

• Antihypertensive drug treatment should be

continued if the BP is high (systolic >150 mm Hg or
diastolic >100 mm Hg).

• Magnesium sulfate (for at least 24 hours) and

antihypertensive drugs may be needed in women
with severe hypertension and symptoms of acute
fulminant pre-eclampsia during the postpartum
period.
 Eclampsia:
PREDICTION AND PREVENTION:
• In majority of cases, eclampsia is preceded by severe pre-
eclampsia.
• eclampsia can occur bypassing the preeclamptic state and as
such, it is not always a preventable condition.
• Eclampsia may present in atypical ways; hence, it is at times
difficult to predict.
• Use of antihypertensive drugs, prophylactic anticonvulsant
therapy and timely delivery are important steps.
• Close monitoring during labor and 24 hours’ postpartum, are
also important in prevention of eclampsia.( Magpie trial
(2002) showed prophylactic use of magnesium sulfate lowers
the risk of eclampsia).
 First aid treatment outside the hospital

Refer to tertiary referral care hospitals

Principles of management at hospital are:

• Maintain: airway, breathing & circulation
• Hemodynamic stabilization (control BP)
• Oxygen administration 8–10 L/min
• Arrest convulsions
• Organize investigations
• Deliver by 6-8 hours
• Ventilatory support
• Prevention of complications
• Prevention of injury
• Postpartum care
 Eclampsia

General supportive management

Detail examinat
history ion Vitals I/O Fetal well
being

Anticonvulsants
Antibiotics
and
sedations

delivery
 Magnesium sulfate is the drug of choice.
does not control hypertension
• acts as a membrane stabilizer and
neuroprotector.
• reduces motor endplate sensitivity to
acetylcholine.
• blocks neuronal calcium influx .
• induces cerebral vasodilatation, dilates uterine
arteries, increases production of endothelial
prostacyclin and inhibits platelet activation.
 Regimens of MgSO4 for the management of
severe pre-eclampsia and eclampsia

Regimen Loading dose Maintenance dose

Intramuscular (Pritchard) 4 gm IV over 3–5 min 5 gm IM 4 hourly in

followed by 10 alternate buttock
gm deep IM (5 gm in each
buttock)

Intravenous (Zuspan or 4–6 gm IV over 15–20 min 1–2 gm/hr IV infusion

Sibai)
Maintenance dose are given only if :
• knee jerks are present (disappears at 10meq/L)
• urine output exceeds 30 mL/hour and
• the respiration rate is more than 12 per minute (12
meq/L) (calcium gluconate or calcium chloride 1 gm)

Therapeutic level of serum magnesium : 4–7 mEQ/L.

• Magnesium sulfate is continued for 24 hours after the
last seizure or delivery whichever is later.
• For recurrence of fits: 2 gm IV bolus is given over 5 min.
Other regimens are:
1. Lytic cocktail :chlorpromazine, promethazine and
pethidine.
2. Diazepam
3. Phenytoin.
Magnesium sulfate has got the following benefits:
• controls fits effectively without any depression
effect to the mother or the infant.
• reduced risk of recurrent convulsions
• significantly reduced maternal death rate (3%) and
• reduced perinatal mortality rate.
Status eclampticus:
• Thiopentone sodium 0.5 gm dissolved in 20 mL of 5%
dextrose – IV
• If the procedure fails- use of complete anesthesia, muscle
relaxant and assisted ventilation.

Pulmonary Edema:
3 common causes of pulmonary edema in women with
severe preeclampsia syndrome—
• pulmonary capillary permeability edema,
• cardiogenic edema, or
• a combination of the two
 Obstetrics management

Antenatal Intranatal Post natal

Fits Fits not

controlled controlled

Baby premature:
Baby dead:
Baby mature : Steroid
Self expulsion
IOL / CS NICU
IOL/CS
IOL/ CS

IOL/CS
 Intranatal Post natal

Close monitoring
Indications of caesarean section:
I. Uncontrolled fits in spite of Vitals
therapy. W/F PPH
II. Unconscious patient and poor Antehypertensive
agents
prospect of vaginal delivery. Continue MgS04
III. Obstetric indications I/O chart
(malpresentation).
Thank you